Transcription of Guam Board of Accountancy
1 guam Board of Accountancy335 South Marine Corps Drive, Suite 101, Tamuning, GU 96913 Tel: 671-647-0813 Fax: 671-647-0816 2/6/2012)Credit CardOne Time Authorization FormInformation about the charge:Please checkthe appropriate box andfill inamount(s): Application Processing:$ Individual Licensure:$ Firm Permit:$ Other:$TotalAmount ofCharge:$CARD INFORMATION: Diners Club MasterCard VISACARD NUMBEREXPIRATION DATE (mm/yy)CVV Security Code (nnn)NAMEON CARD:CARD BILLINGADDRESS:STREET(include Apt #or Suite #)CITYSTATE/TERRITORY/PROVINCE/PREFECTUR EZIP/POSTAL CODECONTACTS:TELEPHONEFACSIMILEEMAILI hereby authorize the guam Board OF Accountancy to charge the credit card notedabove forpayment of the fees and/orexpenses listedabove. I certify that I am an authorized user of this credit card:CARDHOLDERSIGNATUREDATE(FAX completed form to: +1-671-647-0816 OR EMAIL a scanned copy
